Job Summary
We are seeking a highly motivated and detail-oriented CDI (Clinical Documentation Improvement) Specialist to support our client. In this vital role, you will enhance the accuracy, completeness, and quality of medical documentation across various care settings. Your expertise will support clinical teams in ensuring documentation aligns with regulatory standards, coding requirements, and reimbursement policies. This position offers an exciting opportunity to impact patient care quality and optimize revenue cycle processes through meticulous documentation review and clinical collaboration.
Responsibilities
• Review and analyze medical records, clinical documentation, and coding to ensure accuracy and completeness in accordance with clinical documentation standards and health regulation policies.
• Collaborate with physicians, nurses, case managers, and other healthcare professionals to clarify documentation discrepancies and improve the quality of clinical data.
• Utilize electronic health record (EHR) systems
• Conduct utilization review and management activities to support appropriate level of care decisions for inpatient, outpatient, ICU, PICU, neonatal intensive care unit (NICU), and long-term care patients.
• Ensure compliance with Centers for Medicare and Medicaid Services (CMS), NCQA standards, HIPAA regulations, and state healthcare regulations related to medical records and documentation practices.
• Apply ICD-10/ICD-9/ICD coding, CPT coding, DRG assignment, and case management principles to optimize reimbursement while maintaining compliance.
• Participate in discharge planning, hospice care coordination, and post-acute care documentation to support seamless patient transitions across care settings.
• Maintain detailed records of documentation reviews, coding edits, and communication logs for audit purposes.
Requirements
• Proven experience with Epic EMR systems or similar EHR platforms such as Cerner or Athenahealth.
• Strong knowledge of medical terminology, anatomy, physiology, and clinical documentation standards.
• RN with CCDS or CDIP
• Experience in managed care environments with familiarity in Medicare/Medicaid regulations and long-term care regulations.
• Critical care experience including ICU or Level I/II trauma center exposure is highly preferred.
• Inpatient or outpatient experience in hospital settings such as emergency medicine or primary care is advantageous.
• Expertise in ICD-10/ICD-9/ICD coding, CPT coding, DRG assignment, and utilization review processes.
• Knowledge of health information management practices including medical records review and medical management strategies.
• Ability to interpret complex clinical data while ensuring compliance with HIPAA and other privacy laws.
• Excellent communication skills for effective collaboration with multidisciplinary teams across various healthcare environments including nursing homes and clinics.
Pay: $50.00 - $65.00 per hour
Benefits:
• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance
License/Certification:
• RN License (Required)
• CCDS or CDIP (Required)
Work Location: Remote